Thursday, December 20, 2007

"My Doctor" Becomes "The Doctor"

My fellow blogger, Happy Hospitalist, who has added more to our understanding of the economics of our health care crisis than many others after his blog appeared this year, gets to toot his horn a bit more. After all, hospitalists had yet another retrospective, observational study released today in the mighty New England Journal of Medicine that justifies the subspecialty economically.

So it's official: hospitals like hospitalists. And hospitalists like hospitals. Yep, it's a "WIN-WIN" as Happy likes to say.

Now I don't have the time to go into all of the limitations of the study design as reported, but some of the fanciest statistics in the world were used to overcome the admitted limitations of the trial. This certainly didn't thwart the editors and peer reviewers in the Journal from publishing this work - after all there were lots and lots of data. (*Sigh*) But if were to naively accept the results of the study, the bottom line from the authors' analysis suggested that hospitalists save about $268 dollars (less than the cost of a single echocardiogram) and shave off about half a day of hospital time compared to what an general internist or family practitioner could muster without a change in hospital mortality.

Now, don't get me wrong, I think that hospitalists are here to stay. They offer lots of advantages to patients, being omni-present in the hospital and all. But there are some things that our embattled primary care physicians and patients will lose a bit more of because of this economic inevitability: their doctor-patient relationship. Patients no longer are cared for by "my doctor," but rather "the doctor."

And that doctor changes often.

You see, the hospitalist movement requires the "handoff" of the patient from the "primary care" physician to the hospitalist when they enter the hospital. And once in the hospital (what the authors failed to mention), is that at least weekly, and usually nightly, another hospitalist assumes that patient's care. A whole set of re-learning occurs. As though the patient is moving down an industrial assembly line with a different machine applying a few more welds to the final body part.

So patients are left to wonder who, exactly, is their doctor this week or this evening while in the hospital. Whom do they call to find out the results of a test? Whom do they call to discuss an upcoming therapy? Will their (outpatient) doctor have a say in the decisions of day to day care? (Sorry, not really.)

The economics for the field of primary care will also be affected. More and more primary care physicians find they can't compete economically with the salaries of hospitalists. After all, hospitalists have to pay little to no overhead, except their malpractice which is often subsidized by their hospital employer. Additionally, hospitalists' are often incentivised to minimize length of stay with additional bonuses too.

Which leads to the question, where does that extra money paid to hospitalists come from?

A primary care doctor in the outside world must rely on the old economics of the broken Medicare reimbursement system that feeds them mainly a declining "professional" fee for an outpatient office visit. They cannot refer to their own x-ray facility or lab facility due to the Stark II self-referral law that bans such practices. The hospitalists, however, enjoy a slight competetive edge with their income supplied by the omnipotent hospitals who can collect the much larger Medicare "technical" fees from the many procedures ordered by hospitalists and use these funds to support their slightly higher salaries. These incentives are effectively a legal loophole that skirts the well-known Stark II self-referral law. All perfectly legal: after all, they're just "employees" on salary receiving "productivity" bonuses.

So, the primary care doctors are losing a bit more control over their patients and a bit more revenue erosion relative to their hospitalist peers. Patients meanwhile are seeing slightly shorter hospital stays and a more attentive physician presence in the hospital, but are left not knowing who's managing their care.

It's a strange new world of medicine these days - all in the name of efficiency and economics.

4 comments:

My mother just spent from Sunday to Wednesday in the care of an excellent hospitalist.

(Now, I'd worked with her in my husband's extended hospital stay last summer. I knew she was good, to say the LEAST!(45 days to be exact, she'd had my husband for 20 of those days). So, I fully trusted her. Even more after she walked into mom's room, saw me and said "Hi Peggi, how is Don? What's his bipap setting now? How many hours a day on oxygen? Has the nerve damage in his hands improved? Is he walking?" All rapid fire before I could answer a single question.

I wonder, when doctors are interchangeable cogs, how we're supposed to have any capability of choosing? With the old system, you could at least get a word of mouth from friends about a doctor's quality. But you don't get any choice at all with a hospitalist. You get a good one one day, a lousy communicator another day, etc. (And even if all licensed doctors are basically competent, would you, as a doctor, say that all are interchangebly capable in all ways?)

Anony 2:17PM - Great point. Like people, no two hospitalists are alike - you might strike gold one week and have a less-than-enthusiastic doctor the next... so, no, they're not all interchangeable. But to be fair, the weakest ones weed themselves out, too, since they have a hard time juggling the workload (which is considerable in busy hospitals).

I was a hospitalist before I did my cardiology training. I think it depends on what kind of hospitalist you have -- one who clocks in and clocks out, or one who truly cares and takes the time to communicate with the primary care physician. If working with the latter, then a hospitalist is an excellent substitute for a primary care physician in the hospital setting.

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.